Pretracheal (No. 106pre) lymph node metastasis, considered an oligometastatic disease, may achieve long-term survival when treated with modern neoadjuvant therapy combined with surgical resection

Pretracheal (No.106pre) lymph node metastasis in esophageal carcinoma: A sign of widespread disease progression, but potentially treatable as oligometastatic disease through neoadjuvant chemotherapy followed by surgery - A multicenter cohort study.

Objective To investigate the relationship between subgroups of central lymph node metastasis (sCLNM) and lateral lymph node metastasis (LNM) of unilatal papillary thyroid carcinoma (uPTC) with cervical lymph node negative (cN0). Methods The clinical and pathological data of 161 patients with cN0-uPTC who underwent total thyroidectomy+central lymph node dissection+lateral lymph node dissection from Jan. 2016 to Dec. 2016 were retrospectively analyzed. The relationship between the lymph node metastasis of each subarea in the central area of the affected side and the lymph node metastasis of the affected side was investigated. Results Binary logistic regression analysis of cN0-uPTC subregions in the affected central region showed: pre-laryngeal lymph node metastasis, pre-tracheal lymph node metastasis and paratracheal lymph node metastasis were independent risk factors for lymph node metastasis in the affected lateral region (P=0.008, 0.016, 0.035, respectively). Pre-laryngeal lymph node metastasis was an independent risk factor for lymph node metastasis in the affected area II (P=0.015). Pre-tracheal lymph node metastasis was an independent risk factor for lymph node metastasis in affected area III (P=0.004). Pre-tracheal and para-tracheal lymph node metastasis were independent risk factors for lymph node metastasis in the affected IV area (P=0.035, 0.011, respectively). Conclusions The lymph node metastasis pathway of thyroid cancer had certain regularity. The pre-laryngeal lymph node metastasis has the prediction value for the lymph node metastasis of the affected area II. The pre-tracheal lymph node metastasis has the prediction value for the lymph node metastasis of the affected area III. The pre-tracheal and paratracheal lymph node metastasis have the prediction value for lymph node metastasis of the affected area IV. Lymph node dissection in affected areas III and IV needs to be considered in patients with pre-tracheal or paratracheal lymph node metastases. On this basis, lymph node dissection on the affected areas II, III, and IV might be considered if there is pre-laryngeal lymph node metastasis at the same time. Key words: Thyroid neoplasms; Papillary thyroid carcinoma; Lymphatic metastasis; Neck dissection

Advanced esophageal cancer patients with extensive lymph node metastases show extremely poor prognosis and the long-term outcome is poorer with the involvement of more lymph nodes. We report here a long-surviving case of advanced esophageal cancer with histologically 34 lymph node metastases, in which surgical resection with three-field lymphadenectomy followed by adjuvant chemotherapy and radiotherapy was performed. A 53-year-old male was diagnosed as advanced middle esophageal cancer with multiple regional lymph node metastases such as paraesophageal, pretracheal, tracheobronchial and bifurcational lymph nodes and three intramural metastatic lesions. Subtotal esophagectomy with three-field lymphadenectomy was performed for the tumor. Histopathologically, the tumor was poorly differentiated squamous cell carcinoma and 34 lymph nodes including ligamentum arteriosum lymph nodes and pretracheal lymph nodes were proved to be metastatic. Numerous tumor cells were found in the lymphatic vessels near the metastatic lymph nodes. Chemotherapy [3000 mg of 5-fluorouracil (5-FU), 50 mg of cisplatin (CDDP) and 30 mg of methotrexate (MTX)] was administered in two courses, followed by radiation therapy (field size 21 x 20 cm in mediastinum, 10 MV X-rays, 2 Gy/fr, 5 fr/week, total 46 Gy). Subsequently, 1000 mg of 5-FU and 200 mg of CDDP were administered every 3-4 months without any significant toxicities. The patient has been alive and well without recurrence for 5 years following operation. For treatment of advanced esophageal cancer with extensive lymph node metastases, a wide resection of the tumor and regional lymph nodes should be performed, followed by adjuvant chemotherapy and radiotherapy.

ObjectiveThe study aims to explore the possibility of prelaryngeal and/or pretracheal lymph node metastasis in identifying papillary thyroid carcinoma with more than 5 metastatic central lymph nodes from unilateral lobe cT1-2N0 papillary thyroid carcinoma.MethodsA retrospective analysis was conducted on patients who underwent the initial thyroid surgery for unilateral lobe cT1-2N0 PTC in a single tertiary center between July 2018 to December 2022. Multivariable binary logistic regression analysis was used to identify risk factors for unilateral lobe cT1-2N0 papillary thyroid carcinoma with more than 5 metastatic central lymph nodes.ResultsA total of 737 patients were included in the study and 399 patients were confirmed to suffer from occult central lymph node metastasis. The larger size of the largest diameter of tumor (> 1cm; OR = 3.3, 95%CI 1.6 – 6.83; p = 0.001), pretracheal lymph node metastasis (OR = 5.91, 95%CI 2.73 – 12.77; p < 0.001), prelaryngeal lymph node metastasis (OR = 3.74, 95%CI 1.73 – 8.1; p = 0.001), ipsilateral paratracheal lymph node metastasis (OR = 12.22, 95%CI 3.43 – 43.48; p < 0.001), and contralateral paratracheal lymph node metastasis (OR = 7.68, 95%CI 3.86 – 15.3; p < 0.001) were confirmed to be risk factors for unilateral lobe cT1-2N0 PTC with more than 5 metastatic central lymph nodes. When more than two metastatic prelaryngeal and/or pretracheal lymph nodes occurred, the incidence of more than 5 metastatic central lymph nodes was 71.2%.ConclusionPrelaryngeal and/or pretracheal lymph node metastasis could help to identify papillary thyroid carcinoma with more than 5 metastatic central lymph nodes from unilateral lobe cT1-2N0 papillary thyroid carcinoma. When more than two metastatic pretracheal and/or prelaryngeal lymph nodes occurred, total thyroidectomy and ipsilateral central lymph node dissection should be performed and contralateral paratracheal lymph node dissection might be also necessary.

Objective: To explore the risk factors for contralateral central lymph nodes (Cont-CLNs) metastasis of unilateral papillary thyroid carcinoma (PTC) and to guide the decision-making of clinical surgical scope. Methods: The data of 362 patients who underwent total thyroidectomy and bilateral central lymph node dissection at the Sichuan Cancer Hospital from September 2020 to April 2022 and were confirmed as unilateral PTC by postoperative pathology were retrospectively analyzed. Among them, 87 were male and 275 were female, aged from 11 to 76 years. According to whether presence of Cont-CLNs metastasis, they were divided into the metastasis group (115 cases) and the non-metastasis group (247 cases). The relationship between the demographic characteristics, clinicopathological characteristics and other indicators of the two groups of patients and their metastases of Cont-CLNs was analyzed. Univariate analysis, multivariate logistic regression analysis and receiver operating characteristic (ROC) curve analysis were used to screen the risk factors for Cont-CLNs metastasis. Postoperative follow up was performed in the patients. Results: Univariate analysis showed that age, gender, combined Hashimoto's thyroiditis, extranodal invasion, pretracheal and prelaryngeal lymph node metastasis, ipsilateral central lymph nodes (Ipsi-CLNs) metastasis on the affected side, lateral cervical lymph node metastasis on the affected side, lesion location, and tumor diameter were associated with Cont-CLNs metastasis (all P values<0.05). Multivariate revealed that: each of male gender, Ipsi-CLNs metastasis, pretracheal and prelaryngeal lymph node metastasis, cancer focus location in the isthmus, and unilateral glandular lobe combined with isthmus was an independent risk factor for Cont-CLNs metastasis. For predicting the metastasis risk of Cont-CLNs, the optimal critical value of the number of metastasized Ipsi-CLNs was 2.5, and the area under the ROC curve (AUC) was 0.700; the optimal cut-off value of the number of metastasized pretracheal and prelaryngeal lymph nodes was 1, with an AUC of 0.681. The AUC of gender was 0.630, and the AUC of the cancer lesion location was 0.545. Multivariate ROC curve analysis for Cont-CLNs metastasis based on gender, the number of metastasized Ipsi-CLNs, the number of metastasized pretracheal and prelaryngeal lymph nodes, and the location of cancer foci showed an AUC of 0.794. The patients were followed up until January 2025. Excluding 3 cases with hoarseness caused by recurrent laryngeal nerve invasion before the operation and 3 cases with resection and reconstruction of invaded recurrent laryngeal nerves discovered during the operation, there were no patients with permanent recurrent laryngeal nerve palsy after the operation. There were 3 cases with postoperative permanent hypoparathyroidism. There no patients with postoperative recurrence. Conclusion: Risk factors for Cont-CLNs metastasis include male sex, Ipsi-CLNs metastasis, pretracheal and prelaryngeal lymph nodes metastasis, and tumor location in the isthmus or unilateral lobe plus isthmus. In unilateral PTC with the risk factors, Cont-CLNs dissection may be considered.

Background Occult lymph node metastasis of papillary thyroid carcinoma is common. However, whether undergoing prophylactic lateral lymph node dissections is still controversial. This cross-sectional study with large cohort of patients aims to investigate the clinical value of Delphian and pre-tracheal lymph node in predicting lateral lymph node metastasis of papillary thyroid carcinoma. Materials and methods A retrospective analysis was conducted on 865 papillary thyroid carcinoma patients with Delphian and pre-tracheal lymph node data who underwent thyroidectomy plus central and lateral lymph node dissection. Data on clinicopathological characteristics were collected. Subsequently, a predictive model was established based on the results of the univariate and multivariate analyses. Results The rates of Delphian and pre-tracheal lymph node metastasis and lateral lymph node metastasis were 54.7% and 39.1%, respectively. Having ≥ 3 or 1–2 Delphian and pre-tracheal lymph node metastasis dramatically increased the risk of lateral lymph node metastasis (OR = 8.5, 95% CI 5.3–13.4 and OR = 3.9, 95% CI 2.7–5.7, respectively). The upper tumour had a 3.7 times higher risk of lateral lymph node metastasis than other locations. Patients ≤ 42 years or tumour size >8 mm had a higher risk of lateral lymph node metastasis. Conclusions Delphian and pre-tracheal lymph node metastasis was associated positively with the risk of lateral lymph node metastasis. For patients without clinical lateral lymph node metastasis, the Delphian and pre-tracheal lymph node could be considered to harvest as the first step in a thyroidectomy to facilitate further conduct of the operation.

We performed surgical treatment on two patients, each with a solitary metastasis in a mediastinal lymph node from a renal cell carcinoma (RCC). The first case was a 58-year-old male with a chief complaint of chest discomfort due to pretracheal mediastinal lymph node (#3) swelling. He had undergone a right nephrectomy for RCC 13 years previously. Because of difficulty in establishing the diagnosis, a mini-thoracotomy was performed, and this lymphadenopathy was judged to be metastasis from the RCC. The pretracheal lymph nodes were completely resected, and he has experienced no recurrence for two years postoperatively. The second case was a 60-year-old female who had undergone a left nephrectomy for RCC two years previously. Because of the Botallo's lymph node (#5) swelling, a mini-thoracotomy was performed. This swollen lymph node was resected, and it was finally diagnosed to be metastasis from the RCC. Unfortunately, the tumor recurred in the mediastinal lymph nodes with multiple lung metastases five years later. A solitary metastasis in a mediastinal lymph node from a RCC is an unusual event, particularly in the absence of lung metastasis. The diagnostic and clinicopathological problems associated with this unique disease are herein discussed.

The surgical resection range of papillary thyroid microcarcinoma of the isthmus (PTMCI) is controversial, and the guidelines do not fully guide the central lymph node dissection (CLND).We retrospectively studied the comparison of PTMCI (Group A, n = 65 cases) and non-PTMCI (Group B, n = 80 cases). Based on whether central lymph node metastasis (CLNM) was further detected, they were further divided into the PTMCI with CLNM (group C, n = 42 cases), the PTMCI without CLNM (group D, n = 23 cases), the non-PTMCI with CLNM (group E, n = 45 cases), the non-PTMCI without CLNM (group F, n = 35 cases). All patients underwent total thyroidectomy and CLND. The CLNM pathological examination was divided into right recurrent laryngeal nerve superficial lymph nodes (Right VI a), right recurrent laryngeal nerve deep lymph nodes (Right VI b), left VI area lymph nodes (Left VI), prelaryngeal lymph node, and pretracheal lymph node. The extent of lymph node metastasis and risk factors of PTMCI were analyzed by univariate and multivariate analysis. The ROC curve was used to calculate the maximum diameter of the tumor and the Youden index was calculated to analyze the impact of diameter on the risk factors for CLNM in PTMCI. To construct a prediction model of transfer risk of high risk factors by Nomogram, there were significant differences in prelaryngeal lymph nodes (p = 0.034) and pretracheal lymph nodes ( n = 0.035) between group A and group B, and the risk factors of lymph node metastasis were tumor invasion (p = 0.003), multifocality (p = 0.001), and the maximum tumor diameter≧6.5mm. PTMCI is more prone to metastasis of pretracheal lymph nodes and prelaryngeal lymph nodes, and the presence of tumor invasion, multifocality, and tumor diameter≧6.5mm are high risk factors for metastasis in PTMCI. According to the prediction model, with all risk factors the risk of cervical lymph node metastasis is up to 90%.

Invited Commentary

Objective: To examine the correlation factors of contralateral central lymph node metastasis in unilateral papillary thyroid carcinoma with lateral cervical lymph node metastasis. Methods: The clinical data of patients with unilateral papillary thyroid carcinoma who underwent total thyroidectomy and bilateral central lymph node dissection and ipsilateral cervical lymph node dissection from June 2016 to June 2018 at Department of Thyroid Surgery, West China Hospital, Sichuan University were analyzed retrospectively. A total of 317 patients, including 87 males and 230 females, aged (41.4±12.1) years (range: 16 to 75 years), were enrolled in this study. The risk factors of contralateral central lymph node metastasis were analyzed by χ2 test and Spearman correlation analysis. Results: There were 116, 69, 269, and 181 cases of pretracheal lymph node, prelaryngeal lymph node, ipsilateral central lymph node and contralateral central lymph node metastasis, respectively, and 16 cases of skipping metastasis. Univariate analysis showed that contralateral central lymph node metastasis was associated with gender, maximum tumor diameter, capsule invasion, pretracheal lymph node metastasis, prelaryngeal lymph node metastasis, and ipsilateral central lymph node metastasis (all P<0.05). Spearman correlation analysis showed that male (rs=0.162, P=0.004), maximum tumor diameter>10 mm (rs=0.184, P=0.001), capsule invasion (rs=0.135, P=0.016), pretracheal lymph node metastasis (rs=0.394, P<0.01), prelaryngeal lymph node metastasis (rs=0.272, P<0.01) and ipsilateral central lymph node metastasis (rs=0.203, P<0.01) were independent correlation factors for contralateral central lymph node metastasis. Conclusion: For patients with unilateral papillary thyroid carcinoma with ipsilateral cervical lymph node metastasis, bilateral central lymph node dissection should be considered if male, tumor diameter>10 mm, capsule invasion, pretracheal lymph node metastasis, prelaryngeal lymph node metastasis, or ipsilateral central lymph node metastasis.

BackgroundEsophageal squamous cell carcinoma (ESCC) is a common malignant tumor with high disease burden and poor prognosis. Lymph node (LN) metastasis (LNM) is a key prognostic factor for ESCC patients, particularly left gastric artery lymph nodes (No. 7) metastasis. No. 7 LNs dissection is essential for preventing residual tumor and recurrence. However, research on No. 7 LNM in ESCC remains limited. This study aimed to evaluate the independent prognostic role of No. 7 LNM in ESCC and characterize its LNM patterns by comparing isolated No. 7 LNM with No. 7 LNM combined with LNM at other sites.MethodsThis study retrospectively analyzed clinical data from 144 patients with thoracic ESCC who had undergone radical esophagectomy and dissection of No. 7, recurrent laryngeal nerve (RLN, No. 106rec), subcarinal (No. 107), and main bronchial (No. 109) LNs at the Cancer Hospital of the Chinese Academy of Medical Sciences from 2019 to 2021. Postoperative follow-up included routine examinations every 3 months for the first 2 years. Lost-to-follow-up cases underwent standard right-censoring, with these data included in the final analysis. Patients were stratified into the No. 7-positive group (No. 7 LN+) and the No. 7-negative group (No. 7 LN−) based on postoperative pathological detection of No. 7 LNM. Kaplan-Meier survival analysis was used to assess the overall survival (OS) and disease-free survival (DFS) in patients with ESCC, and the Cox proportional hazards regression model was applied to identify the independent risk factors associated with OS and DFS.ResultsAmong 144 patients with thoracic ESCC, 75 had lower thoracic tumors, 124 received neoadjuvant therapy, and 115 had pathological stage N0–N1 disease. This study analyzed the association between No. 7 LNM and prognosis in these patients. Kaplan-Meier curves showed significantly poorer OS (P=0.007) and DFS (P=0.009) in the No. 7 LN+ group than the No. 7 LN− group. Multivariate Cox regression identified No. 7 LNM as an independent factor influencing the OS (P=0.03) and DFS (P=0.04) of patients with ESCC. Subgroup analysis of patients with No. 7 LNM revealed no significant differences in OS (P=0.33) or DFS (P=0.37) between patients with ESCC with and without 106rec LNM. However, patients with concurrent 107 LNM or 109 LNM had significantly poorer OS (P=0.02) and DFS (P=0.03) compared with those without such metastases. Furthermore, lower-thoracic ESCC patients in the No. 7 LN+ group had significantly poorer OS (P=0.04) and DFS (P=0.04) than the No. 7 LN− group. Sensitivity analysis of patients who received neoadjuvant therapy confirmed the results were robust.ConclusionsOur study confirms that No. 7 LNM is an indicator of poor prognosis in patients with thoracic ESCC. Standardized dissection of No. 7 LNs is critical during radical esophagectomy for thoracic ESCC.

160P Is it possible to omit axillary surgery in patients with cN0, postmenopausal ER+HER2- breast cancer who perform breast-conserving surgery?

Background: Lymph node (LN) metastasis is a strong predictor of unfavorable prognosis for patients with periampullary adenocarcinoma after surgical resection. We sought to assess the prognostic performance of several LN staging systems, including American Joint Committee on Cancer (AJCC)/ International Union Against Cancer (7th edition) N stage, the total number of LN (TLN), the number of metastatic LN (MLN), the lymph node ratio (LNR) and the log odds of MLNs (LODDS), in patients with periampullary adenocarcinoma after surgical resection and identify the optional LN staging system to accurately stratify patients with different prognoses.Methods: We retrospectively analyzed 205 patients with periampullary adenocarcinoma after surgical resection. The predictive effects of several LN staging systems on overall survival (OS) and progression free survival (PFS) for all included patients and patients with more than 12 TLNs examined were evaluated and compared using the time-dependent receive operating characteristic (ROC) curve and decision curve analysis (DCA), respectively.Results: Eighty-nine patients (43.4%) had LN metastasis and their survival was not significantly decreased compared with patients without LN metastasis. LODDS and LNR were able to stratify patients into various subgroups with significant differences of both OS and PFS. When assessed using ROC curve and DCA, LODDS outperformed LNR and other LN staging systems in predicting OS and PFS. In addition, when analyzed in patients with more than 12 TLNs examined, LODDS had a higher value of area under ROC curve (AUC) and showed better performance of DCA.Conclusion: LODDS performs better than other LN staging systems in predicting OS and PFS for patients with periampullary adenocarcinoma after surgical resection. Adequate LN dissection is necessary for curative surgery, as well as to achieve a more accurate staging of the disease and a more precise prediction of survival for these patients.

ObjectiveWe conducted a meta-analysis to study the relationship between pretracheal and/or prelaryngeal lymph node metastasis and paratracheal and lateral lymph node metastasis in papillary thyroid carcinoma.MethodA systematic literature search was conducted using PubMed, Embase, and the Cochrane Library electronic databases for studies published up to February 2022. The reference lists of retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the overall pooled relative risk. Publication bias in these studies was evaluated using Egger’s test and Begg’s test.ResultsTwenty-five independent studies involving 10,525 patients were included in the meta-analysis. The pooled relative risk for ipsilateral and contralateral paratracheal lymph node metastasis was 3.01 (95% confidence interval [CI]: 1.66, 5.45) and 5.68 (95% CI: 2.50, 12.88), respectively, in patients with pretracheal lymph node metastasis. Among patients with prelaryngeal lymph node metastasis, the pooled relative risk for ipsilateral paratracheal and/or pretracheal contralateral paratracheal, and lateral lymph node metastasis was 2.02 (95% CI: 1.90, 2.14), 2.22 (95% CI: 1.34, 3.67), and 3.85 (95% CI: 2.89, 5.14), respectively.ConclusionPretracheal lymph node metastasis and prelaryngeal lymph node metastasis were significantly associated with an increased likelihood of both ipsilateral lymph node metastasis and contralateral paratracheal lymph node metastasis in papillary thyroid carcinoma. Prelaryngeal lymph node metastasis was positively correlated with the incidence of lateral lymph node metastasis.

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